PONE-D-23-14896Predictors of Institutional Delivery Service Utilization among Women in Northern Region of GhanaPLOS ONE

Dear Dr. Mohammed,

Thank you for submitting your manuscript to PLOS ONE. After careful consideration, we feel that it has merit but does not fully meet PLOS ONE’s publication criteria as it currently stands. Therefore, we invite you to submit a revised version of the manuscript that addresses the points raised during the review process.

==============================Reviewer 1 comments:Methods:

Page 7 : Sample size determination and sampling process

line 146- 150 ; details on how the 8 districts and two communities were randomly selected should be given

How was the sampling frame of 5 arrived at?

How was the southward direction decided to be followed first until there were no more houses before other directions from the start point?

Discussion: Page 16

Line: 267-271; “ The disparity in the reported prevalence…………….” Explain why recruiting women who have given birth in the previous year would give such different prevalence from the women recruited from the reproductive age or expectant mothers?

Any recent studies from the respective countries referenced in your study? Reviewer 2 comments

PONE-D-23-14896 MANUSCRIPT REVIEWERS COMMENTS

ABSTRACT

Stop first sentence at” morbidity and mortality”

There on free maternal health care but NHIS

Why did you not study the prevalence and predictors of home delivery? Some reasons why they delivered at home may still remain unknown.

Conclusion: What is “availability of skilled personnel”?

LINES 25-39: The comments above also apply to this section

LINES 47-48 When does a woman become A SINGLE MOTHER? Is it when she is pregnancy or after delivery.? Are they unmarried pregnant women? Teenagers? or their husbands travelled while they were pregnant?

LINES 54-73: These definitions are not necessary in the manuscript

LINE 76: ..in the “reproductive process”….this is not clear. You need to it up from the reference 1.

METHODS

LINES 122: Data collected from 10^th March- 2^nd April 2023 and compare to -lines 31: Jan 2022 to Jan 2023. Put the two sentences together so that it becomes clear what you want to do.

What is community chairman? Chairman of what?

LINE 163: Needs clarity. Respondents were recruited at the starting point and every fifth house was visited.

LINE 172: What about COVID 19? When you are collecting data in March- April 2023.

RESULTS IN THE TABLES

TABLES 1: Differences between divorced and single. Almost 38% (119) were single women in those rural communities yet 245 husbands had positive or negative attitudes as shown in table 4.

That makes total number of husbands 54 more than your study of 310 respondents. Are some of the women having more than a husband or what. In the same table 4, under husband’s occupation total is 320 also more than your study of 310 respondents.

Where from these errors? How do these errors affect your findings and conclusions?

DISCUSSION

LINES 317-344

How is the impact of pregnancy schools relevant in this study which was in a rural population?. Something you found in your study attracts them to health facilities so discuss that more.

CONCLUSION LINES 329-331: The major issue with the conclusion is that there is no clear understanding of who is a single mother.

The data from tables 1 & 4 are conflicting on marital status of the women, attitudes of the husbands and number of husbands in the various occupations listed.

REFEENCES

All references must conform to Journals referencing style/format

Some references are incomplete eg 22 and 23 are not complete

Reviewer 3 comments

Introduction

Use of safe and effective delivery services including place of delivery is an important component of the Safe Motherhood concept. Hence, assessing predictors of institutional delivery could contribute to improving birth outcomes in the study setting.

Minor revisions

1. There are more recent estimates of global maternal mortality. The authors are advised to use these (eg Trends in maternal mortality 2000 to 2020: estimates by WHO, UNICEF, UNFPA, World Bank Group and UNDESA/Population Division. Geneva: WHO 2023).

2. Line 59: The definition given is that of maternal mortality ratio rather the rate.

3. A few sentences need to be edited eg line 95 “…sustainable development goal…” should be written as “…Sustainable Development Goal...”. Lines 139 and 226 should be in the past tense; ie reside and perceive respectively should be in the past tense.

4. Some acronyms were used without defining them at the first instance eg CHPS, DHS, MIS, WHO etc. Acronyms/abbreviations used in Tables should all be defined below the table.

5. Study setting: The authors should state the population of WRA in the region.

6. Methods: The selected districts together with the number of women selected from each district should be stated.

7. Line 188: Although the authors stated that there were some exclusions due to missing data, there is no evidence to support this as the estimated sample size (310) is exactly the same as the number of women surveyed. It appears all women approached agreed and participated in the study. Otherwise, they should state the number of women who were excluded.

8. Ethical considerations: The authors should clearly describe how consent was obtained from minors (ie women <18 years of age)

9. Provide refs for the sampling procedure described on page 8 and pregnancy schools in Ghana (lines 317-324), which could be of interest to readers.

10. The authors should provide the mean age, standard deviation and the range.

11. In Table 4, there is no need to indicate ** against significant p-values as the authors have indicated in the methods section that p<0.05 will be considered statistically significant. I believe all stated p-values in the table will be interpreted in that context. The authors rounded off some ORs from Table 4 in the text (see lines 237-247). The authors should state ORs in the text as they are in the table for ease of reference. They also repeated some ORs with their 95% CIs within the same paragraph and in some instances the ORs were different (eg lines 239 and 244; and 237 and 246). As much as possible, the authors should avoid repeating results especially within the same paragraph. They can make their point without repeating the results.

12. The authors should provide areas for further research in the conclusion.

Major revisions

1. My major concern with the study is the sample size and its estimation. I do not think a sample of 310 is representative enough of the entire population of women of reproductive age (WRA) in the Northern region of Ghana. What is the population of WRA in the region? The stated sample size only estimated a single proportion of home deliveries without incorporating the predictors of home deliveries (such as the proportions and measures of association eg ORs as used in this study). Besides, no adjustments were made for the community-based sampling technique eg could the design effect be modified?

2. In line 193 the authors stated the criteria for inclusion into the multivariable model as p<0.05 in the univariable analysis. Yet in Table 4, several variables with p>0.05 in the univariable analysis were included in the multivariable analysis (age group, religion, educational level, occupation, husband occupation). The multivariable analysis should be re-run without these covariates ie ensuring that only covariates which meet the inclusion criteria are included in the multivariable model.

3. The authors should discuss the limitations of the study.

==============================

Please submit your revised manuscript by Sep 01 2023 11:59PM. If you will need more time than this to complete your revisions, please reply to this message or contact the journal office at plosone@plos.org . When you're ready to submit your revision, log on to https://www.editorialmanager.com/pone/ and select the 'Submissions Needing Revision' folder to locate your manuscript file.

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If you would like to make changes to your financial disclosure, please include your updated statement in your cover letter. Guidelines for resubmitting your figure files are available below the reviewer comments at the end of this letter.

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We look forward to receiving your revised manuscript.

Kind regards,

Kwaku Asah-Opoku

Academic Editor

PLOS ONE

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Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

1. Is the manuscript technically sound, and do the data support the conclusions?

The manuscript must describe a technically sound piece of scientific research with data that supports the conclusions. Experiments must have been conducted rigorously, with appropriate controls, replication, and sample sizes. The conclusions must be drawn appropriately based on the data presented.

Reviewer #1: Yes

Reviewer #2: No

Reviewer #3: Yes

**********

2. Has the statistical analysis been performed appropriately and rigorously?

Reviewer #1: Yes

Reviewer #2: No

Reviewer #3: No

**********

3. Have the authors made all data underlying the findings in their manuscript fully available?

The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified.

Reviewer #1: No

Reviewer #2: No

Reviewer #3: Yes

**********

4. Is the manuscript presented in an intelligible fashion and written in standard English?

PLOS ONE does not copyedit accepted manuscripts, so the language in submitted articles must be clear, correct, and unambiguous. Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here.

Reviewer #1: Yes

Reviewer #2: Yes

Reviewer #3: Yes

**********

5. Review Comments to the Author

Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters)

Reviewer #1: Methods:

Page 7 : Sample size determination and sampling process

line 146- 150 ; details on how the 8 districts and two communities were randomly selected should be given

How was the sampling frame of 5 arrived at?

How was the southward direction decided to be followed first until there were no more houses before other directions from the start point?

Discussion: Page 16

Line: 267-271; “ The disparity in the reported prevalence…………….” Explain why recruiting women who have given birth in the previous year would give such different prevalence from the women recruited from the reproductive age or expectant mothers?

Any recent studies from the respective countries referenced in your study?

Reviewer #2: ABSTRACT

Stop first sentence at” morbidity and mortality”

There on free maternal health care but NHIS

Why did you not study the prevalence and predictors of home delivery? Some reasons why they delivered at home may still remind unknown.

Conclusion: What is “availability of skilled personnel”?

LINES 25-39: The comments above also apply to this section

LINES 47-48 When does a woman become A SINGLE MOTHER? Is it when she is pregnancy or after delivery.? Are they unmarried pregnant women? Teenagers? or their husbands travelled while they were pregnant?

LINES 54-73: These definitions are not necessary in the manuscript

LINE 76: ..in the “reproductive process”….this is not clear. You need to it up from the reference 1.

METHODS

LINES 122: Data collected from 10th March- 2nd April 2023 and compare to -lines 31: Jan 2022 to Jan 2023. Put the two sentences together so that it becomes clear what you want to do.

What is community chairman? Chairman of what?

LINE 163: Needs clarity. Respondents were recruited at the starting point and every fifth house was visited.

LINE 172: What about COVID 19? When you are collecting data in March- April 2023.

RESULTS IN THE TABLES

TABLES 1: Differences between divorced and single. Almost 38% (119) were single women in those rural communities yet 245 husbands had positive or negative attitudes as shown in table 4.

That makes total number of husbands 54 more than your study of 310 respondents. Are some of the women having more than a husband or what. In the same table 4, under husband’s occupation total is 320 also more than your study of 310 respondents.

Where from these errors? How do these errors affect your findings and conclusions?

DISCUSSION

LINES 317-344

How is the impact of pregnancy schools relevant in this study which was in a rural population?. Something you found in your study attracts them to health facilities so discuss that more.

CONCLUSION LINES 329-331: The major is

Reviewer #3: Introduction

Use of safe and effective delivery services including place of delivery is an important component of the Safe Motherhood concept. Hence, assessing predictors of institutional delivery could contribute to improving birth outcomes in the study setting.

Minor revisions

1. There are more recent estimates of global maternal mortality. The authors are advised to use these (eg Trends in maternal mortality 2000 to 2020: estimates by WHO, UNICEF, UNFPA, World Bank Group and UNDESA/Population Division. Geneva: WHO 2023).

2. Line 59: The definition given is that of maternal mortality ratio rather the rate.

3. A few sentences need to be edited eg line 95 “…sustainable development goal…” should be written as “…Sustainable Development Goal...”. Lines 139 and 226 should be in the past tense; ie reside and perceive respectively should be in the past tense.

4. Some acronyms were used without defining them at the first instance eg CHPS, DHS, MIS, WHO etc. Acronyms/abbreviations used in Tables should all be defined below the table.

5. Study setting: The authors should state the population of WRA in the region.

6. Methods: The selected districts together with the number of women selected from each district should be stated.

7. Line 188: Although the authors stated that there were some exclusions due to missing data, there is no evidence to support this as the estimated sample size (310) is exactly the same as the number of women surveyed. It appears all women approached agreed and participated in the study. Otherwise, they should state the number of women who were excluded.

8. Ethical considerations: The authors should clearly describe how consent was obtained from minors (ie women <18 years of age)

9. Provide refs for the sampling procedure described on page 8 and pregnancy schools in Ghana (lines 317-324), which could be of interest to readers.

10. The authors should provide the mean age, standard deviation and the range.

11. In Table 4, there is no need to indicate ** against significant p-values as the authors have indicated in the methods section that p<0.05 will be considered statistically significant. I believe all stated p-values in the table will be interpreted in that context. The authors rounded off some ORs from Table 4 in the text (see lines 237-247). The authors should state ORs in the text as they are in the table for ease of reference. They also repeated some ORs with their 95% CIs within the same paragraph and in some instances the ORs were different (eg lines 239 and 244; and 237 and 246). As much as possible, the authors should avoid repeating results especially within the same paragraph. They can make their point without repeating the results.

12. The authors should provide areas for further research in the conclusion.

Major revisions

1. My major concern with the study is the sample size and its estimation. I do not think a sample of 310 is representative enough of the entire population of women of reproductive age (WRA) in the Northern region of Ghana. What is the population of WRA in the region? The stated sample size only estimated a single proportion of home deliveries without incorporating the predictors of home deliveries (such as the proportions and measures of association eg ORs as used in this study). Besides, no adjustments were made for the community-based sampling technique eg could the design effect be modified?

2. In line 193 the authors stated the criteria for inclusion into the multivariable model as p<0.05 in the univariable analysis. Yet in Table 4, several variables with p>0.05 in the univariable analysis were included in the multivariable analysis (age group, religion, educational level, occupation, husband occupation). The multivariable analysis should be re-run without these covariates ie ensuring that only covariates which meet the inclusion criteria are included in the multivariable model.

3. The authors should discuss the limitations of the study.

**********

6. PLOS authors have the option to publish the peer review history of their article (what does this mean? ). If published, this will include your full peer review and any attached files.

If you choose “no”, your identity will remain anonymous but your review may still be made public.

Do you want your identity to be public for this peer review? For information about this choice, including consent withdrawal, please see our Privacy Policy .

Reviewer #1: Yes:  Kareem Mumuni

Reviewer #2: No

Reviewer #3: No

**********

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Attachments

Attachment

Submitted filename: PONE-D-23-14896 Review comments.docx

PONE-D-23-14896R1Predictors of Institutional Delivery Service Utilization among Women in Northern Region of GhanaPLOS ONE

Dear Dr. Mohammed,

Thank you for submitting your manuscript to PLOS ONE. After careful consideration, we feel that it has merit but does not fully meet PLOS ONE’s publication criteria as it currently stands. Therefore, we invite you to submit a revised version of the manuscript that addresses the points raised during the review process.

Please submit your revised manuscript by Oct 05 2023 11:59PM. If you will need more time than this to complete your revisions, please reply to this message or contact the journal office at plosone@plos.org . When you're ready to submit your revision, log on to https://www.editorialmanager.com/pone/ and select the 'Submissions Needing Revision' folder to locate your manuscript file.

Please include the following items when submitting your revised manuscript:

• A rebuttal letter that responds to each point raised by the academic editor and reviewer(s). You should upload this letter as a separate file labeled 'Response to Reviewers'.
• A marked-up copy of your manuscript that highlights changes made to the original version. You should upload this as a separate file labeled 'Revised Manuscript with Track Changes'.
• An unmarked version of your revised paper without tracked changes. You should upload this as a separate file labeled 'Manuscript'.

If you would like to make changes to your financial disclosure, please include your updated statement in your cover letter. Guidelines for resubmitting your figure files are available below the reviewer comments at the end of this letter.

If applicable, we recommend that you deposit your laboratory protocols in protocols.io to enhance the reproducibility of your results. Protocols.io assigns your protocol its own identifier (DOI) so that it can be cited independently in the future. For instructions see: https://journals.plos.org/plosone/s/submission-guidelines#loc-laboratory-protocols . Additionally, PLOS ONE offers an option for publishing peer-reviewed Lab Protocol articles, which describe protocols hosted on protocols.io. Read more information on sharing protocols at https://plos.org/protocols?utm_medium=editorial-email&utm_source=authorletters&utm_campaign=protocols .

We look forward to receiving your revised manuscript.

Kind regards,

Kwaku Asah-Opoku

Academic Editor

PLOS ONE

[Note: HTML markup is below. Please do not edit.]

Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

1. If the authors have adequately addressed your comments raised in a previous round of review and you feel that this manuscript is now acceptable for publication, you may indicate that here to bypass the “Comments to the Author” section, enter your conflict of interest statement in the “Confidential to Editor” section, and submit your "Accept" recommendation.

Reviewer #1: All comments have been addressed

Reviewer #2: All comments have been addressed

Reviewer #3: (No Response)

**********

2. Is the manuscript technically sound, and do the data support the conclusions?

The manuscript must describe a technically sound piece of scientific research with data that supports the conclusions. Experiments must have been conducted rigorously, with appropriate controls, replication, and sample sizes. The conclusions must be drawn appropriately based on the data presented.

Reviewer #1: (No Response)

Reviewer #2: Yes

Reviewer #3: Partly

**********

3. Has the statistical analysis been performed appropriately and rigorously?

Reviewer #1: (No Response)

Reviewer #2: Yes

Reviewer #3: No

**********

4. Have the authors made all data underlying the findings in their manuscript fully available?

The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified.

Reviewer #1: (No Response)

Reviewer #2: Yes

Reviewer #3: (No Response)

**********

5. Is the manuscript presented in an intelligible fashion and written in standard English?

PLOS ONE does not copyedit accepted manuscripts, so the language in submitted articles must be clear, correct, and unambiguous. Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here.

Reviewer #1: (No Response)

Reviewer #2: Yes

Reviewer #3: Yes

**********

6. Review Comments to the Author

Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters)

Reviewer #1: (No Response)

Reviewer #2: No more comments

The authors have answered all the questions that were asked in the initial review.

Recommended for publication

Reviewer #3: Thank you very much for carrying out most of the suggested revisions. There are still a few revisions that need to be addressed to further improve the quality of the manuscript.

1. My “introduction” was meant to be a preamble to my review and not meant to be incorporated into the abstract. Hence it was not part of the suggested revisions. However, if the authors find it useful to include it in the introduction of the abstract, that is fine with me. While the authors have included the statements (from my introduction) in the abstract within the main manuscript, the statements not in the abstract that is in the preliminary pages of the manuscript.

2. In response to suggested minor revision # 7 the authors wrote: Kindly see lines 297 – 298 “Overall, 340 women were surveyed in the study and 91.2% (310/340) agreed to participate in the study”.

The authors should kindly state at least some of the reasons why people were excluded.

3. In response to suggested minor revision #10, the authors wrote: “The variable age was collected as a categorical variable, this makes it impossible to present the summary statistics as proposed by the reviewer.”

It is important to state the mean and standard deviation for age as a continuous variable. Age as a continuous variable should not have been categorized/grouped at the data collection stage. The authors should have collected individual ages and grouping/categorization done at the analysis stage. If this was not done, there are still ways of estimating the mean and standard deviation of the data such as using the midpoint of each age group and the respective frequencies. The authors should kindly consult a statistician on how to do this.

4. In response to suggested major revision #1, the authors stated that:

The sample size was based on the number of deliveries recorded since our target population was women who had given birth a year prior to the study. So, although there is a large population of WRA in the region, the estimated number of deliveries in the region is much lower. Also, the design effect was adjusted for in the data analysis, where robust standard errors using the type of community as a clustering variable was conducted.

I think my fundamental point is that a sample estimation for predictors of institutional deliveries that makes use of only the prevalence of institutional deliveries without taking into account any of the predictors of institutional deliveries is problematic and may not be adequately powered to detect these predictors. The use of robust standard errors will not adequately deal with the issue of community-based sampling. Given that the data has already been collected, one way round this is to discuss the inadequately powered sample size as a limitation of the study.

5. In response to suggested major revision #2, the authors stated that:

The strategy used in selecting variables for the adjusted logistic regression analysis has been revised. Kindly see lines 270 – 271 “The adjusted logistic regression model's variables were selected using the stepwise regression approach”.

Which technique was used in adding or eliminating the variables in the stepwise approach? In the two common variable selection approaches in logistic regression (forward selection and backward elimination (selection) methods), the final multivariable model includes variables that are significantly associated with the outcome of interest (based on the authors’ criteria, here p<0.05, using a model fitness test). This will typically exclude all variables that were not significant in the univariable analysis (unless they were considered to be a priori). In addition, it may exclude some variables which were significant in the univariable analysis but were not significantly associated with outcome of interest in the multivariable model based on the model fitness test. Hence, the following variables which were not significant in the univariable model (all p>0.05) should NOT be included in the final multivariable model: age group, religion, educational level, occupation, husband occupation, National Health Insurance Scheme ownership, and attitudes of husbands towards facility delivery.

The authors can please refer to:

Hosmer Jr DW, Lemeshow S and Sturdivant RX (2013). Applied Logistic Regression. 3rd Edition. New York: John Wiley and Sons, Inc.

**********

7. PLOS authors have the option to publish the peer review history of their article (what does this mean? ). If published, this will include your full peer review and any attached files.

If you choose “no”, your identity will remain anonymous but your review may still be made public.

Do you want your identity to be public for this peer review? For information about this choice, including consent withdrawal, please see our Privacy Policy .

Reviewer #1: Yes:  Kareem Mumuni

Reviewer #2: No

Reviewer #3: No

**********

[NOTE: If reviewer comments were submitted as an attachment file, they will be attached to this email and accessible via the submission site. Please log into your account, locate the manuscript record, and check for the action link "View Attachments". If this link does not appear, there are no attachment files.]

While revising your submission, please upload your figure files to the Preflight Analysis and Conversion Engine (PACE) digital diagnostic tool, https://pacev2.apexcovantage.com/ . PACE helps ensure that figures meet PLOS requirements. To use PACE, you must first register as a user. Registration is free. Then, login and navigate to the UPLOAD tab, where you will find detailed instructions on how to use the tool. If you encounter any issues or have any questions when using PACE, please email PLOS at figures@plos.org . Please note that Supporting Information files do not need this step.

PONE-D-23-14896R2Predictors of Institutional Delivery Service Utilization among Women in Northern Region of GhanaPLOS ONE

Dear Dr. Mohammed,

Thank you for submitting your manuscript to PLOS ONE. After careful consideration, we feel that it has merit but does not fully meet PLOS ONE’s publication criteria as it currently stands. Therefore, we invite you to submit a revised version of the manuscript that addresses the points raised during the review process.

==============================

ACADEMIC EDITOR:  Authors should kindly address the following concerns

Introduction

1. The authors cited the 2019 facility delivery rate in Ghana. Can they look at the current rate from the Ghana Demographic Health Survey and argue from there very well?
2. Can they also state the regional institutional delivery rate in their argument, especially in the problem statement
3. The study gap is not very clear. The authors should clearly state some of the articles in the area, especially in Ghana and the Northern part of the country, and their gap.
4. The authors should indicate the rationale of the study. That piece is missing in the introduction.
5. There should be a theory for the study.

Methodology

1. I believe some districts may have more communities than others, so selecting 16 communities from each district would bias the sampling; how did the authors deal with districts with more communities?  
2. Can the authors state the lowest and highest number of communities for the districts selected?
3. The authors indicated that the kth interval used in selecting households can be specific on the number.
4. This statement, “For each community, the sampling interval (K) was determined as the total number of houses divided by the number of women to be sampled from the community, ” and another statement, “A respondent was recruited at the starting point, and every fifth house starting from the southward direction was visited ” are conflicting statements. This statement needs to be well explained. Does this mean that the sampling interval was used differently in each community? The authors should add a supplementary sheet on how the sampling was done concerning the communities and the selection of houses.
5. There should be a section on the measurement of variables. Clearly describe how the dependent variable and the independent variables were measured.
6. Authors should state when the data was collected (month and year).

Results

1. The authors should elaborate clearly on how the variables were selected for the logistic regression (Table 4). What were the criteria for reducing the variables to only 4?

Discussion

Link the theory to the discussion.

Recommendation

“The recommendation of the study is not very strong. For instance, “To increase health facility delivery, we recommend the Ministry of Health should institute a policy reform with a well-defined care package targeting unmarried pregnant women and health workers with a negative attitude and community perception.” Can authors suggest a policy in that direction? They should add other recommendations, especially given the context that most of the communities are rural

==============================

Please submit your revised manuscript by Oct 05 2024 11:59PM. If you will need more time than this to complete your revisions, please reply to this message or contact the journal office at plosone@plos.org . When you're ready to submit your revision, log on to https://www.editorialmanager.com/pone/ and select the 'Submissions Needing Revision' folder to locate your manuscript file.

Please include the following items when submitting your revised manuscript:

• A rebuttal letter that responds to each point raised by the academic editor and reviewer(s). You should upload this letter as a separate file labeled 'Response to Reviewers'.
• A marked-up copy of your manuscript that highlights changes made to the original version. You should upload this as a separate file labeled 'Revised Manuscript with Track Changes'.
• An unmarked version of your revised paper without tracked changes. You should upload this as a separate file labeled 'Manuscript'.

If you would like to make changes to your financial disclosure, please include your updated statement in your cover letter. Guidelines for resubmitting your figure files are available below the reviewer comments at the end of this letter.

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We look forward to receiving your revised manuscript.

Kind regards,

Martin Wiredu Agyekum, PhD

Guest Editor

PLOS ONE

Journal Requirements:

Please review your reference list to ensure that it is complete and correct. If you have cited papers that have been retracted, please include the rationale for doing so in the manuscript text, or remove these references and replace them with relevant current references. Any changes to the reference list should be mentioned in the rebuttal letter that accompanies your revised manuscript. If you need to cite a retracted article, indicate the article’s retracted status in the References list and also include a citation and full reference for the retraction notice.

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Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

1. If the authors have adequately addressed your comments raised in a previous round of review and you feel that this manuscript is now acceptable for publication, you may indicate that here to bypass the “Comments to the Author” section, enter your conflict of interest statement in the “Confidential to Editor” section, and submit your "Accept" recommendation.

Reviewer #1: All comments have been addressed

Reviewer #3: All comments have been addressed

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2. Is the manuscript technically sound, and do the data support the conclusions?

The manuscript must describe a technically sound piece of scientific research with data that supports the conclusions. Experiments must have been conducted rigorously, with appropriate controls, replication, and sample sizes. The conclusions must be drawn appropriately based on the data presented.

Reviewer #1: Yes

Reviewer #3: Yes

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3. Has the statistical analysis been performed appropriately and rigorously?

Reviewer #1: Yes

Reviewer #3: Yes

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The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified.

Reviewer #1: Yes

Reviewer #3: Yes

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5. Is the manuscript presented in an intelligible fashion and written in standard English?

PLOS ONE does not copyedit accepted manuscripts, so the language in submitted articles must be clear, correct, and unambiguous. Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here.

Reviewer #1: Yes

Reviewer #3: Yes

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Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters)

Reviewer #1: Your manuscript has been appropriately revised and reviewer's comments has been .adequately addressed.

Reviewer #3: No further comments .

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Reviewer #1: Yes:  Mumuni Kareem

Reviewer #3: No

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While revising your submission, please upload your figure files to the Preflight Analysis and Conversion Engine (PACE) digital diagnostic tool, https://pacev2.apexcovantage.com/ . PACE helps ensure that figures meet PLOS requirements. To use PACE, you must first register as a user. Registration is free. Then, login and navigate to the UPLOAD tab, where you will find detailed instructions on how to use the tool. If you encounter any issues or have any questions when using PACE, please email PLOS at figures@plos.org . Please note that Supporting Information files do not need this step.

Predictors of Institutional Delivery Service Utilization among Women in Northern Region of Ghana

PONE-D-23-14896R3

Dear Dr. Mohammed,

We’re pleased to inform you that your manuscript has been judged scientifically suitable for publication and will be formally accepted for publication once it meets all outstanding technical requirements.

Within one week, you’ll receive an e-mail detailing the required amendments. When these have been addressed, you’ll receive a formal acceptance letter and your manuscript will be scheduled for publication.

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Kind regards,

Mubarick Nungbaso Asumah, MPhil, Bsc

Academic Editor

PLOS ONE

Additional Editor Comments (optional):

Reviewers' comments: